Ayden Healthcare Of Greenville
Inspection history, citations, penalties and survey trends for this long-term care facility in Greenville, Ohio.
- Location
- 243 Marion Drive, Greenville, Ohio 45331
- CMS Provider Number
- 365532
- Inspections on file
- 25
- Latest survey
- December 4, 2025
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Ayden Healthcare Of Greenville during CMS and state inspections, most recent first.
Staff did not allow a food processor to air dry after sanitizing before use, placed food in the still-wet processor, and served sandwiches below the required hot holding temperature. Additionally, silverware was handled without gloves, with mouth-contact surfaces touched during tray preparation, contrary to facility policy.
Surveyors found that several opened eye drop bottles and ointments were either missing open dates or being used beyond the recommended four-week period after opening. LPNs confirmed these issues during interviews, and the deficiency affected multiple residents whose medications were stored on the observed medication carts.
A resident was found to have a made bed with a top blanket containing two large, light brown stains. The resident did not know the origin of the stains and expressed not wanting dirty bedding. A CNA confirmed the bed was made with the stained blanket.
A resident who was fully dependent on staff was found with a hematoma and blood on her pillow, and staff were unable to explain the cause of the injury. There were inconsistencies in staff accounts regarding who assisted with the resident's transfer, and the assigned LPN did not immediately assess the injury, deferring to the DON. The facility did not follow its abuse policy, which required immediate assessment and documentation for injuries of unknown origin.
A resident who was dependent on staff for all ADLs and had multiple chronic conditions was found with a hematoma and blood on her pillow, with no explanation for the injury. The incident was documented and reported internally, but the DON confirmed it was not reported to the state agency as required by facility policy.
A resident who was dependent on staff for all ADLs and had multiple medical conditions was found with a head hematoma and bleeding, with staff providing inconsistent accounts of when and how the injury was discovered and whether proper transfer procedures were followed. The facility's investigation was incomplete, missing key witness statements and documentation, and did not adhere to policy requirements for investigating injuries of unknown origin.
A resident with multiple complex medical conditions and dependence on staff for oral hygiene experienced ongoing mouth pain and required dental extractions. Despite documented dental issues and interventions, the facility did not develop a care plan to address the resident's dental needs, pain, or required extractions, as confirmed by staff and record review.
A resident with hemiplegia and muscle weakness, who required staff assistance for ADLs, did not consistently receive oral care twice daily as recommended by a dentist. Documentation and interviews confirmed that oral care was often only provided on shower days, contrary to facility policy and care recommendations.
A resident with multiple chronic conditions and intact cognition was not provided with an activities program that supported their preferences, including not being invited to desired group activities. Documentation showed the resident was frequently marked as unavailable despite being present in the facility, and participation was limited to independent activities, contrary to facility policy requiring individualized activity offerings.
During a meal service, several residents on a puree diet were served food items that did not match the prescribed menu, including regular tomato soup without crackers and cottage cheese instead of pureed cantaloupe. The Dietary Director confirmed these substitutions, which were not supported by a written order as required by facility policy.
Staff did not wear required PPE, specifically gowns, while providing high-contact care to a resident on Enhanced Barrier Precautions due to a stage IV pressure ulcer and indwelling catheter. This occurred despite facility policy and CDC guidance mandating gown use for such care activities.
A resident with cognitive impairment and high dependence on staff was found to have a non-functional call light in their room, which did not activate in the room, hallway, or nursing station. The issue was confirmed by the Maintenance Director, and facility policy required staff to notify maintenance of such problems.
A CNA failed to follow infection control protocols during incontinence care for a resident with multiple chronic conditions, including removing a soiled dressing, using the same wipe on both the anal area and an open wound, and not performing hand hygiene immediately after care. The DON confirmed that these actions were not in line with facility policy and expectations.
Two residents received PRN psychotropic medications without proper documentation of medical indications, re-evaluation dates, or duration of use. Orders for antianxiety and antipsychotic medications were administered over multiple days without required monitoring or justification, and pharmacy recommendations for review were not acted upon in a timely manner.
A resident with severe cognitive impairment and multiple medical conditions had two distinct pressure ulcers, but only one was treated as ordered due to incomplete wound documentation. During wound care, an LPN treated only one wound because records did not specify both ulcers, and the wound care clinician confirmed that assessments combined both wounds into a single measurement, contrary to facility policy.
A resident with multiple medical conditions, including depression and bipolar disorder, did not receive a prescribed dose of Venlafaxine ER 150 mg because the medication was not available during a medication pass. A nurse confirmed the medication could not be found in the medication cart, overflow, or emergency box, contrary to facility policy requiring timely and safe administration of medications.
A resident receiving insulin injections for diabetes was administered doses from two insulin pens that were not dated when opened, contrary to facility policy requiring multi-dose containers to be labeled with the date of first use. The administering RN confirmed the absence of opening dates on both pens.
The facility failed to pay its contracted extermination services, resulting in the cessation of monthly treatments for infestations. This affected a resident whose belongings were infested with bed bugs, as no extermination services were provided to address the issue. The administrator confirmed the non-payment and lack of services since August 2024.
A facility failed to ensure all nurses had active licenses, resulting in an LPN working with an expired license. The issue was discovered during a complaint investigation, and the IDON confirmed the LPN worked post-expiration. An assessment of residents and medication audits showed no issues.
The facility failed to maintain its pest control program due to nonpayment, affecting all 67 residents. Services were discontinued after August 2024, confirmed by the extermination service and the facility's administrator. A resident's belongings were infested with bed bugs, and without extermination services, the facility could not treat them, violating the facility's pest control policy.
A resident with a prosthetic leg was admitted to a facility with a bed bug infestation. The facility failed to treat the prosthetic for bed bugs due to unpaid extermination services, leaving the resident without the prosthetic and impacting therapy sessions. Staff attempts to clean the prosthetic were unsuccessful, and the resident expressed agitation over the missing prosthetic.
A resident with dementia and other conditions was found with a laceration on the right lower leg, and the cause was unknown. Despite finding scissors with apparent blood in the room, the facility did not investigate or report the incident to the state as required by their policy. Staff confirmed the incident was reported internally, but no further action was taken.
A resident with dementia and other conditions was found with a leg laceration of unknown origin. Despite the presence of scissors with apparent blood in the room, the facility did not investigate or report the incident as required by policy. Staff confirmed the incident was reported to the DON, but no further action was taken, leading to non-compliance with regulations.
Failure to Maintain Safe and Sanitary Food Preparation and Handling
Penalty
Summary
Staff failed to prepare and handle food in a safe and sanitary manner, as observed during the preparation of puree diets. A staff member was seen cleaning a food processor in a three-compartment sink, then immediately assembling it and adding sandwiches without allowing the processor to air dry. The staff member confirmed that the inside of the food processor was still wet with sanitizer when food was placed inside. Additionally, ham and cheese sandwiches stored on the steam table were found to be at 125 degrees Fahrenheit, below the required minimum hot holding temperature of 135 degrees Fahrenheit. The staff member verified the temperature was below standard and later checked the sandwiches again, finding them at 132.8 degrees Fahrenheit, still not meeting the minimum requirement. Further observations revealed another staff member placing silverware on residents' lunch trays without wearing gloves and touching the mouth-contact surfaces of other spoons while removing a spoon from an unorganized container. This was confirmed by another staff member, who then reorganized the spoons to prevent contamination. The facility's policy on food preparation and handling requires food to be kept free of harmful organisms and substances, which was not followed in these instances.
Failure to Properly Label and Dispose of Ophthalmic Medications
Penalty
Summary
Surveyors observed that the facility failed to ensure proper labeling and timely disposal of ophthalmic medications, specifically eye drops and ointments, in accordance with professional standards. During inspection of two medication carts, several opened eye drop bottles were found either lacking an open date or being used beyond the recommended four-week period after opening. For example, one resident's artificial tears were open and dated over three months prior, while another resident's latanoprost solution had no open date but was nearly empty. Additional observations revealed other eye drop bottles and ointments with either missing open dates or open dates exceeding the four-week usage guideline. Interviews with LPNs confirmed the absence of open dates on some medications and the use of products past the recommended timeframe. The review of The International Pharmacopoeia guidance indicated that multidose ophthalmic drop preparations should be used for up to four weeks after opening. These findings affected six residents whose medications were stored on the observed carts, and the facility census at the time was 65.
Failure to Ensure Clean Bed Linens for Resident
Penalty
Summary
A deficiency was identified when a resident's bed was observed to have a large, oblong light brown stain, approximately 12 inches by 6 inches, and a second similar stain below it, on the top white blanket. The bed was made with the sides and end of the blanket tucked under the mattress. During an interview, the resident was unable to identify the source of the stain but expressed a desire not to have stained or dirty bedding. A certified nursing assistant confirmed the presence of the stains and that the bed had been made in this condition.
Failure to Follow Abuse Policy for Injury of Unknown Origin
Penalty
Summary
The facility failed to follow its abuse policy in response to an injury of unknown origin involving one resident. The resident, who was dependent on staff for all activities of daily living and had diagnoses including chronic obstructive pulmonary disease, type 2 diabetes mellitus, and hypertension, was found during morning care with a small amount of blood on her pillow and a hematoma on the side of her head. The source of the injury was not observed, and the resident was unable to explain what happened. Staff interviews and witness statements revealed inconsistencies regarding who assisted with the resident's transfer and the sequence of events, with some staff unable to provide details or denying involvement. The nurse assigned to the resident did not immediately assess the injury, stating that the DON was handling the incident. Review of the facility's policy indicated that staff should immediately report all incidents and not move a resident with a suspected injury until assessed by a nurse supervisor. The policy also required documentation of the assessment, physician and representative notification, and treatment provided. In this case, the required immediate assessment and clear documentation were not completed as specified, and the incident was not managed in accordance with the established abuse policy for injuries of unknown origin.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the state surveying agency as required by policy. Medical record review showed that a resident with chronic obstructive pulmonary disease, type 2 diabetes mellitus, and hypertension, who was dependent on staff for all activities of daily living, was found with a hematoma and a small amount of blood on her pillow during morning care. The source of the injury was not observed, and the resident was unable to explain what happened. The incident was documented in the facility's incident log, and staff reported the findings to nursing. Despite the facility's policy requiring immediate reporting of all injuries of unknown source to the Administrator or designee and notification of the state agency within two hours if serious bodily injury is identified, the Director of Nursing confirmed that the incident was not reported to the State Surveying Agency. The failure to report was identified through medical record review, incident log review, staff interview, and policy review, and affected one resident out of five reviewed during the survey.
Failure to Thoroughly Investigate Resident Injury of Unknown Origin
Penalty
Summary
The facility failed to conduct a thorough and timely investigation into an injury of unknown source involving a resident who was dependent on staff for all activities of daily living and had significant medical conditions, including chronic obstructive pulmonary disease and type 2 diabetes mellitus. The resident was found with a hematoma and bleeding on her head during morning care, with staff noting blood on her pillow and a bump on her head. The resident was unable to communicate what had happened, and staff provided inconsistent accounts regarding when the injury was first identified, who was present during transfers, and whether proper two-person assistance was provided during mechanical lift transfers. The facility's incident investigation was incomplete and did not adhere to its own policy, which required interviewing all relevant witnesses, including staff from prior shifts and family members who had contact with the resident. Key witness statements were missing, such as from the staff member who assisted with the transfer the previous evening and from the resident's husband, who was present the night before the injury was discovered. Additionally, the investigation did not document important details, such as the placement and condition of the Hoyer lift, or whether there was any blood on the equipment or elsewhere in the room. Staff interviews revealed confusion and lack of clarity about the events leading up to the injury, with some staff unable to confirm who assisted with transfers or whether proper procedures were followed. The facility prematurely concluded that the Hoyer lift bar caused the injury before gathering all necessary statements and evidence. The investigation was not completed within the required timeframe, and documentation was insufficient to determine the cause of the injury, resulting in a deficiency for failure to thoroughly investigate an injury of unknown origin.
Failure to Address Dental Needs in Care Plan
Penalty
Summary
The facility failed to develop and implement a care plan addressing the dental needs of a resident who was dependent on staff for all activities of daily living, including oral hygiene. The resident had multiple diagnoses, including Parkinson's disease, malnutrition, HIV, diabetes, and a history of adult physical abuse. Medical record review showed the resident was moderately cognitively impaired and required supervision with eating, as well as full assistance with personal care. The resident experienced mouth and facial pain, discomfort with chewing, and specifically reported a toothache in the right lower jaw. Hospice was notified, and the resident was started on antibiotics for a bacterial infection. A dental visit resulted in a referral for extractions, but review of the care plan revealed there was no documentation addressing the resident's dental needs, mouth pain, or the need for extractions. Staff interviews confirmed the absence of a care plan for these issues, despite the resident's ongoing dental pain and the need for intervention. Facility policy required care plans to be based on comprehensive assessments and developed by the interdisciplinary team, but this was not followed in the resident's case.
Failure to Provide Consistent Oral Care Assistance
Penalty
Summary
The facility failed to provide appropriate oral care to a resident who was unable to perform oral hygiene independently. The resident, who had a history of hemiplegia and hemiparesis following a cerebral infarction and muscle weakness, was cognitively intact and required assistance with activities of daily living. According to the medical record and oral care log, staff did not consistently offer or provide oral care twice daily as recommended by the dentist. Documentation showed that on multiple dates, oral care was only offered once per day, and the resident confirmed that staff typically only brushed his teeth on days when he received a shower. Interviews with the resident and the Director of Nursing verified the lack of documentation and the inconsistency in providing oral care as required by facility policy. The facility's policy stated that appropriate care and services would be provided to residents unable to carry out activities of daily living independently, but this was not followed in the case of this resident.
Failure to Provide Resident-Directed Activities Program
Penalty
Summary
The facility failed to provide an activities program that supported residents in their choice of activities, as evidenced by the experience of one resident. This resident, who had multiple significant diagnoses including cancer, chronic heart failure, COPD, Parkinson's disease, diabetes, and chronic kidney disease, was cognitively intact and required substantial to maximum assistance with mobility and dressing. The resident's care plan included interventions such as monitoring for changes in activity participation, providing 1:1 activities as needed, offering items for self-directed activities, encouraging new activities, and reassessing activity interests. Despite these interventions, the resident reported not being invited to desired activities such as bingo and expressed dissatisfaction with the lack of available activities. Review of activity participation documentation showed the resident was marked as unavailable for activities 71 times and refused 15 times over a two-month period, with participation limited to independent activities like current events, socializing, and television. The administrator confirmed the resident was almost always present in the facility and could not explain why the resident was repeatedly marked as unavailable. Facility policy required activities to be offered based on individual preferences and needs, with participation documented in the medical record, but this was not followed in the resident's case.
Failure to Follow Prescribed Puree Diet Menu
Penalty
Summary
The facility failed to follow the prescribed menu for residents on a puree diet, as observed during a lunch service. Specifically, three residents who required a puree diet were served regular tomato soup without crackers and cottage cheese instead of the menu-specified pureed tomato soup with crackers and pureed cantaloupe. Additionally, apple sauce was served in place of pureed cantaloupe. The Dietary Director confirmed these deviations from the menu, and a review of the facility's policy indicated that texture modification diets should be followed as ordered, with no changes made without a written order.
Failure to Use Required PPE During Enhanced Barrier Precautions
Penalty
Summary
Staff failed to follow infection prevention and control protocols for a resident who was under Enhanced Barrier Precautions (EBP) due to a stage IV pressure ulcer and an indwelling catheter. Specifically, observation revealed that a Certified Nursing Assistant (CNA) exited the resident's area after changing the resident's brief and performing peri-care without wearing a gown, which is required under EBP for high-contact care activities. The CNA confirmed during an interview that neither they nor the assisting CNA wore a gown during the procedure, despite being aware of the EBP requirements. Record review showed that the resident had significant medical conditions, including active primary progressive multiple sclerosis and epilepsy, and had an active physician order for EBP. Facility policy and CDC guidance both require the use of gowns and gloves during high-contact care activities for residents with wounds or indwelling medical devices. The failure to use appropriate PPE during these activities constituted a breach of the facility's infection control policy and CDC recommendations.
Non-Functional Call Light in Resident Room
Penalty
Summary
A deficiency was identified when a resident's call light was found to be non-functional during an observation. The resident, who had diagnoses including Parkinson's disease and major depressive disorder, was moderately cognitively impaired and dependent on staff for toileting, personal hygiene, and transfers. The resident's fall care plan included an intervention to ensure the call light was within reach. However, on the date of observation, the call light in the resident's room was not working and did not activate in the room, hallway, or nursing station. This was confirmed by the Maintenance Director. The facility's policy required staff to notify maintenance if call lights were not functioning.
Infection Control Lapse During Incontinence Care
Penalty
Summary
During incontinence care for a resident with multiple diagnoses including diabetes mellitus type II, morbid obesity, depression, and chronic obstructive pulmonary disease, a Certified Nursing Assistant (CNA) failed to follow proper infection control practices. The resident, who was cognitively intact and dependent on staff for bed mobility, transfers, and toileting hygiene, was observed lying in bed when the CNA donned personal protective equipment and began care. The CNA removed the resident's incontinence product, cleansed the peri area, and then removed a soiled bordered dressing from the resident's left buttock, revealing a shallow open area. The CNA continued to cleanse the resident, using wipes to clean stool from both the anal area and the open wound, sometimes using the same wipe for both areas before disposal. The CNA did not perform hand hygiene immediately after providing care and before leaving the resident's room, instead applying hand sanitizer only after returning from disposing of soiled items in the utility room. The CNA confirmed during an interview that she had removed the dressing, which was not her responsibility, and acknowledged not performing hand hygiene at the appropriate time. The Director of Nursing confirmed that CNAs are expected to provide incontinence care but not to remove dressings, and that hand hygiene should be performed immediately after care and before leaving the resident's room. Facility policy also requires thorough cleansing and hand hygiene after incontinence care, which was not followed in this instance.
Lack of Documentation and Monitoring for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that psychotropic medications prescribed to residents had appropriate documentation for medical use, including clear indications, re-evaluation dates, and duration of use. For one resident with diagnoses including dysphagia, tremors, dementia, osteoarthritis, and adult failure to thrive, a physician order for Lorazepam as needed (PRN) for anxiety did not specify a re-evaluation or duration date. The medication was administered daily over multiple days, and the order was only later changed to include a 14-day duration. For another resident with encephalopathy, hypotension, Alzheimer's disease, and atrial fibrillation, a PRN order for Haloperidol for agitation also lacked a re-evaluation or duration date, and the resident did not have a documented medical diagnosis supporting the use of this antipsychotic. The medication was administered on multiple days across two months. A pharmacy medication regimen review recommended re-evaluation and the addition of a stop date for the Haloperidol order, but this recommendation was not reviewed or signed by the physician until the resident was about to be discharged. The Director of Nursing confirmed that both residents' PRN psychotropic medication orders lacked required re-evaluation and duration dates, and that the medical record did not show adequate indications for the use of Haloperidol. Facility policy required that each resident's medication regimen be managed and monitored for dose, duration, indication, and clinical need, but these requirements were not met for the residents reviewed.
Failure to Properly Assess and Treat Multiple Pressure Ulcers
Penalty
Summary
The facility failed to properly assess and treat pressure ulcers for a resident with multiple complex medical diagnoses, including multiple sclerosis, quadriplegia, and myelodysplastic syndrome. Medical record review showed that the resident had a Stage IV pressure ulcer present upon admission, and weekly wound assessments were being conducted. However, the documentation only included measurements for the entire affected area and did not provide separate descriptions or measurements for each distinct pressure ulcer. During wound care observation, two separate wounds were identified on the resident's right buttock/sacrum area, but only one wound received the prescribed treatment. The LPN performing the care stated that the documentation did not indicate a second pressure ulcer, so treatment was only applied to one wound. Further interviews confirmed that the wound care clinician was aware of two distinct pressure ulcers but had only documented the area as a whole, not individually. The facility's policy required individualized treatment and assessment for each pressure injury, but this was not followed. As a result, one of the resident's pressure ulcers did not receive the ordered treatment, and the documentation failed to accurately reflect the resident's wound status. This deficiency was identified during a complaint investigation and affected one resident reviewed for wound care.
Medication Not Available for Administration
Penalty
Summary
The facility failed to ensure that medications were available for administration as prescribed, resulting in a deficiency affecting one resident. Medical record review showed that the resident, who had diagnoses including heart disease, diabetes mellitus, atrial fibrillation, depression, and bipolar disorder, was admitted and had a physician's order for Venlafaxine ER 150 mg daily for depression. During a medication pass observation, a registered nurse was unable to locate the resident's prescribed Venlafaxine ER 150 mg tablet in the medication cart, overflow, or emergency box, confirming the medication was not available for administration. Facility policy required medications to be administered safely, timely, and as prescribed, which was not followed in this instance.
Insulin Pens Not Dated Upon Opening
Penalty
Summary
The facility failed to ensure that insulin injector pens were properly dated when opened, as required by professional standards and facility policy. During medication administration for a resident with multiple diagnoses including diabetes mellitus, gas gangrene, chronic osteomyelitis, peripheral vascular disease, and hypertension, it was observed that both the Insulin Glargine and Insulin Lispro pens used for the resident did not have an opening date indicated on them. The registered nurse who administered the insulin confirmed that neither pen was dated to show when it was first opened. Review of the facility's medication administration policy revealed that staff are required to record the date on multi-dose containers when they are opened and to check expiration or beyond-use dates prior to administration. Despite this policy, the insulin pens in use for the resident were not dated, representing a failure to follow established procedures for medication labeling and storage.
Facility's Non-payment Leads to Cessation of Extermination Services
Penalty
Summary
The facility failed to maintain financial solvency by not paying its contracted extermination services, which were scheduled to provide monthly treatments for infestations. The contract with the extermination service began in February 2024, but the facility had not received any invoices after August 20, 2024. This non-payment led to the cessation of extermination services, as confirmed by the exterminator's receptionist during an interview on December 26, 2024. The lack of extermination services directly impacted the care of a resident who was admitted from the hospital on September 25, 2024, and subsequently readmitted. The resident's personal belongings, which were infested with bed bugs, were bagged and stored outside the facility. Due to the outstanding balance with the exterminator, no services were provided to eradicate the bed bugs from the resident's belongings. The facility administrator confirmed the non-payment and the absence of extermination services since August 2024. This deficiency was identified during a complaint investigation.
Expired Nursing License Deficiency
Penalty
Summary
The facility failed to ensure that all nurses providing care to residents had active licenses, as required by state law. Specifically, a Licensed Practical Nurse (LPN) was found to have an expired license while continuing to work at the facility. The Ohio Board of Nursing License Verification database confirmed that the LPN's license had expired, and the facility's daily nursing schedules showed that the LPN was scheduled to work after the expiration date. The Human Resource Manager confirmed that the LPN worked with an expired license on her last day of work. The Interim Director of Nursing (IDON) verified that the LPN had worked after her license expired and stated that the issue was discovered and addressed by management. The IDON conducted an assessment of all residents cared for by the LPN and found no issues or concerns with the nursing care provided. Additionally, an audit of medications administered by the LPN revealed no errors. The deficiency was identified during a complaint investigation related to specific complaint numbers.
Failure to Maintain Pest Control Program
Penalty
Summary
The facility failed to maintain a pest control program in accordance with its policy, which had the potential to affect all 67 residents. The facility had a contract with an extermination service to provide monthly pest control services, but the services were discontinued after August 2024 due to nonpayment. This lapse in service was confirmed through interviews with the extermination service's receptionist and the facility's administrator, who acknowledged the unpaid balance and the cessation of services. The deficiency was further highlighted by an incident involving a resident who was admitted from the hospital and had their personal belongings infested with bed bugs. Due to the lack of extermination services, the facility was unable to treat the resident's belongings, which were instead bagged and stored outside. The facility's pest control policy, dated October 2019, mandates an ongoing pest control program to keep the building free of pests, but this was not adhered to, leading to the deficiency noted in the complaint investigation.
Failure to Provide Prosthetic Due to Untreated Bed Bug Infestation
Penalty
Summary
The facility failed to provide appropriate care and assistance for a resident with a prosthesis by not timely treating the prosthetic device for bed bugs. The resident, who had a traumatic leg amputation and other medical conditions, was admitted with a prosthetic leg infested with bed bugs. Upon admission, the resident's belongings, including the prosthetic, were bagged and placed in a contained area outside the facility due to the infestation. However, the facility did not contact an exterminator to treat the items because of an unpaid balance with the extermination service provider. The resident's medical records and therapy notes indicated that the absence of the prosthetic leg was a barrier to the resident's therapy sessions and independence. Despite the resident's need for the prosthetic to improve mobility and independence, the facility did not ensure the prosthetic was decontaminated and returned to the resident. The resident expressed agitation over the missing prosthetic, and therapy sessions were impacted due to its unavailability. Interviews with facility staff revealed that attempts to clean the prosthetic with insecticide were unsuccessful, and the facility's environmental manager confirmed that no extermination efforts had been made. The facility's administrator acknowledged the unpaid extermination services and the lack of extermination since August 2024. The facility's failure to address the bed bug infestation and provide the resident with a usable prosthetic leg resulted in a deficiency during the complaint investigation.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin involving a resident to the State Agency, as required by their policy and regulations. The resident, who has dementia, retrograde amnesia, falls, and asthma, was found with a laceration on the right lower leg. The injury was discovered by a nurse during bed rounds, and the resident was unable to explain how it occurred. The wound was assessed, and the resident was sent to the hospital for treatment. Despite the presence of scissors with apparent blood on them found in the room, the facility did not conduct a thorough investigation or report the incident to the state. Interviews with staff, including LPNs and RNs, confirmed that the injury's cause was unknown and that the incident was reported to the Director of Nursing. However, the facility did not follow through with an investigation or report the injury as required by their policy. The facility's policy mandates that all reports of abuse, including injuries of unknown source, must be reported to state agencies and thoroughly investigated, which was not done in this case.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for Resident #15, who was admitted with diagnoses including dementia, retrograde amnesia, falls, and asthma. The resident, who required complete assistance for activities of daily living, was found with a laceration on the right lower leg. The injury was discovered during a bed round by an aide, and the resident was unable to explain how it occurred. The nurse assessed the wound, notified the physician and family, and sent the resident to the hospital for treatment. Despite the presence of scissors with apparent blood on them found in the room, the facility did not document or investigate the cause of the injury. Interviews with staff, including LPN #111 and RN #400, confirmed the presence of scissors and the reporting of the incident to the Director of Nursing (DON). However, the DON acknowledged that the facility did not investigate or report the injury as required by their policy. The facility's policy mandates that all reports of abuse, including injuries of unknown source, must be reported to state agencies and thoroughly investigated. The failure to investigate and report the incident represents non-compliance with the facility's policy and regulations.
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Surveyors found that multiple hazardous storage areas, including a closet near medical records, a beauty salon used to store chemical cases, a supply room in one nursing station, a room leading to a smoking area, a housekeeping room near therapy, and a lobby storage room, lacked required self-closing or automatic-closing doors. These conditions did not comply with NFPA 101 requirements for hazardous area enclosure and had the potential to affect all residents and staff in an emergency.
Surveyors found that the facility did not conduct fire drills on every shift each quarter and did not vary drill conditions as required by NFPA 101. Record review showed that one shift lacked a documented drill for an entire quarter, and the pattern of drill times and dates did not demonstrate varied conditions. The Maintenance Director confirmed the incomplete and noncompliant fire drill schedule, which affected all residents and staff emergency preparedness.
Surveyors found that the facility did not maintain clear egress corridors as required by NFPA 101, with a TV/video cart plugged into a corridor outlet and multiple unsecured chairs placed in the hallway near resident rooms and the secured unit dining room, including directly in front of a fire extinguisher. These items projected about 29 inches into an approximately eight-foot-wide corridor and were located in front of the handrail, potentially affecting 28 residents and staff’s ability to assist in an emergency. The Maintenance Director confirmed these corridor obstructions during the survey.
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
A cognitively intact resident with behavioral issues, including physical aggression and noncompliance with care, was in a secured unit and was observed tapping on the window/door. A dietary aide, despite being told by a CNA and an RN not to enter the secured unit and that the resident’s assigned aide could assist, went onto the unit and interacted with the resident, including offering to buy a soda after seeing money in the resident’s hand. The resident struck the aide in the face, and the aide responded by punching the resident in the face; a CNA reported hearing the aide say, “I will hit you again,” and then observed the resident bleeding. The resident was later found at the hospital to have an open mandibular fracture and non-restorable teeth requiring extraction, and the facility’s investigation and policy definitions led to the incident being substantiated as staff-to-resident physical abuse.
A resident with severe cognitive impairment, osteoporosis, and total dependence for transfers was being moved from bed to wheelchair with a mechanical lift when CNAs reported that an undersized sling and a forceful pull on the lift caused the resident to fall feet‑first from the sling, with staff catching the upper body while both legs struck the floor and one leg bent behind. Witnesses heard a loud pop and observed immediate pain, bruising, swelling, and deformity of the leg, yet the responding LPN did not complete a thorough musculoskeletal assessment, did not document a fall, and the physician and resident representative were not promptly informed of a suspected injury. Through the night and into the next day, staff and the roommate reported the resident crying out in pain and an obviously abnormal leg, but nursing notes only reflected intermittent acetaminophen administration without clear pain documentation, and the physician was contacted primarily about yelling and behavior. Mobile X‑rays obtained later showed a displaced distal femur fracture, which was not reviewed until the following day, when hospital imaging confirmed a closed displaced comminuted femur fracture and a hand fracture. The facility’s internal investigation was incomplete and inaccurate, with leadership denying a fall, preparing a single typed statement minimizing the event, and having multiple staff sign it despite later testimony that the statement was false and that staff were told not to discuss the incident.
Surveyors found multiple instances of improper food storage and labeling, including undated and unlabeled opened dairy products, beverages, and prepared foods in the main walk-in cooler and freezer, as well as a serving scoop left resting directly on stored pasta. Additional issues included covered but undated pre-poured juices, milk, and thickened beverages in a reach-in cooler used for tray line, and a nurses' station refrigerator containing a dated bag of a resident’s food from over a week prior and three undated half-sandwiches. In a resident’s personal refrigerator, staff confirmed three undated bags of grapes with visible mold. These conditions did not comply with facility policies requiring cold foods to be stored off the floor, wrapped or covered, labeled, dated, and for resident refrigerators to be monitored daily with unsafe or moldy food discarded.
Surveyors found unsanitary kitchen conditions, including a dirty tray holding clean pitchers, soiled storage carts containing clean dishware and disposables, and multiple trays of open juice in a reach-in refrigerator that were unlabeled and undated. In a walk-in refrigerator, they observed a bag of bologna marked only with a freeze date, lacking a thaw or use-by date, and appearing slimy and discolored. Observation of the high-temp dishwasher showed rinse temperatures below the 180°F minimum required for hot water sanitizing, and review of several months of temperature logs revealed repeated sub-minimum wash and rinse temperatures and numerous missing entries. Facility policies required dishwashing to meet specified temperature standards and all refrigerated foods to be covered, labeled, and dated with a use-by date, but these requirements were not consistently followed.
Surveyors found that the facility did not maintain a safe, clean, and homelike environment as required by its policy. In one shared bedroom, wallpaper was peeling in several areas, including behind each bed, below a window, and near baseboards, and a black substance was present around the base of the toilet. A CNA confirmed these conditions. In addition, three cracked or broken light covers were observed in a hall restroom. These environmental issues affected two residents and had the potential to affect all residents.
Failure to Maintain Self-Closing Doors for Multiple Hazardous Storage Areas
Penalty
Summary
Surveyors identified a deficiency related to hazardous area protection and door requirements under NFPA 101, 2012 Edition. During facility tours, they observed that multiple hazardous storage areas did not have self-closing or automatic-closing doors as required for hazardous areas such as combustible storage and chemical storage. These areas included a closet next to medical records, a beauty salon being used to store cases of chemicals, a supply room in Station #2, and the room leading to the smoking area in Station #3. On a subsequent tour, surveyors observed additional hazardous areas without self-closing doors. The housekeeping room across from therapy and the lobby storage room were both noted to lack self-closing door mechanisms. The facility census at the time was 59 residents, and the surveyors stated that this deficient practice had the potential to affect all residents and staff's ability to assist in an emergency. The Maintenance Director verified these findings at the time they were observed.
Plan Of Correction
K 0321 This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be admissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 06/12/2026 K-0321 Doors with Self-Closing Devices Corrective action for resident/s: 1. The closet door next to medical records was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing device to closet door next to medical records on or before 06/12/2026 in accordance with applicable code. 2. The beauty salon had chemicals stored in it on 5/19/2026. Maintenance director moved chemicals from beauty salon on 05/20/2026 in accordance with applicable code. 3. The supply room on station 2 was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing door to supply room on station 2 on or before 06/12/2026 in accordance with applicable code. 4. The room to the smoking area on station 3 was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the smoking are on station 3 on or before 06/12/2026 in accordance with applicable code. 4. The housekeeping room across from therapy was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the housekeeping room across from therapy gym on or before 06/12/2026 in accordance with applicable code. 5. The lobby storage room was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the lobby storage room on or before 06/12/2026 in accordance with applicable code. Identification of other residents who may be affected: LNHA and Maintenance director/designee completed a full facility audit for doors with self-closing devices on 05/26/2026. Any corrective action, including, doors identified as needing self-closures will be added on or before 06/09/2026 in accordance with applicable code. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 sections 19.3.2.1 and 19.3.5.9 specifically regarding doors with self-closing devices. How Corrective Action will be monitored Ongoing "Doors with Self-Closing device audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 06/12/2026
Failure to Conduct Required Quarterly Fire Drills on All Shifts
Penalty
Summary
The facility failed to conduct fire drills in accordance with NFPA 101, 2012 Edition, sections 19.7.1 through 19.7.1.8, specifically by not holding drills every shift each quarter and not varying drill conditions as required. Record review on 06/09/25 at approximately 10:32 A.M. showed there was no fire drill conducted for the first shift during the third quarter. The documented first-shift fire drills occurred on 01/30/26 at 2:42 P.M., 04/30/26 at 1:51 P.M., and 10/31/25 at 10:58 A.M., indicating a missed quarter. Second-shift fire drills were recorded on 02/26/26 at 5:20 P.M., 06/03/25 at 4:35 P.M., 08/29/25 at 3:46 P.M., and 11/25/25 at 5:09 P.M., and third-shift drills on 02/28/26 at 11:47 P.M., 05/30/25 at 12:18 A.M., 07/22/25 at 11:34 P.M., 09/26/25 at 11:40 P.M., and 12/15/25 at 5:17 A.M. The surveyor determined that drills were not conducted under varied conditions and that the required quarterly drill on each shift was not consistently performed. The Maintenance Director confirmed these findings at the time they were identified, and the deficiency had the potential to affect all 59 residents and staff response in an emergency. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency related to facility-wide emergency preparedness practices and documentation of fire drills.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0712 Fire Drills Corrective action for resident/s: There were no records of a fire drill for the first shift of the third quarter of 2025. First shift fire drill completed on 5/24/2026 by maintenance director/designee with no findings or corrective action necessary. Identification of other residents who may be affected: On 5/26/2026 Maintenance director/designee completed 100% audit of the scheduled fire drills to ensure a drill is scheduled quarterly each shift with no findings or corrective action necessary. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 section 19.7.1.4 through 19.7.1.7. specifically including fire drill frequency requirements. How Corrective Action will be monitored Ongoing "Fire Drill Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Obstructed Egress Corridors Due to Equipment and Chairs
Penalty
Summary
The facility failed to maintain required clear egress widths in corridors in accordance with NFPA 101, 2012 Edition, sections 19.2.3.4 through 19.2.3.5 and 7.3.2 through 7.3.2.3, creating projections into the egress corridor that exceeded allowable limits. Surveyors observed that on one day in Station #3, a cart with a television and video equipment was plugged into an outlet in the corridor by room 38, and five activity room chairs were placed in the corridor near the secured unit dining room directly in front of a fire extinguisher. On the following day, surveyors again observed chairs in the Station #3 corridor, with four by room 35 and four by the activities room, and the same television cart still in the corridor; the chairs were not secured. The corridor was approximately eight feet wide, and the projections extended approximately 29 inches into the corridor in front of the handrail. These conditions had the potential to affect 28 residents in the facility and the staff’s ability to assist in an emergency, and the Maintenance Director confirmed the observations at the time of discovery. No specific resident medical histories or conditions were described in the report, only that 28 residents were potentially affected and the facility census was 59.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be subsequent remedial measures and should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0232 Clear path of egress Corrective action for resident/s: 1. On 05/18/2026 station 3 had a cart with a television parked in the corridor by room 38 that exceeded allowable limits. Maintenance director/designee moved the TV cart into the activity room, out to the corridor on 05/18/2026 in accordance with applicable code. 2. On 5/18/2026 station 3 had 5 chairs in the corridor near the dining room directly in front of the fire extinguisher. Maintenance director/designee moved the chairs into the dining room, out of the corridor on 5/18/2026 in accordance with applicable code. 3. On 5/19/2026 station 3 had 4 chairs by the activity room and 4 by room 35. In addition, the TV cart was in the corridor. The maintenance director/designee moved the chairs and TV cart into the dining room, out of the corridor on 5/19/2026 in accordance with applicable code. Identification of other residents who may be affected: Maintenance director/designee completed a 100% facility audit for clear paths of egress on 5/26/26 with no findings or corrective action necessary. Measures for systemic change: Maintenance Director/designee educated staff on 5/26/2026 regarding NFPA 101-2012 section 19.2.3.4 and 19.2.3.5 specifically including maintaining a clear path of egress. How Corrective Action will be monitored Ongoing "Path of Egress Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Staff-to-resident physical abuse resulting in jaw fracture and tooth loss
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from staff-to-resident physical abuse, resulting in serious injury. A dietary aide entered a secured unit where a cognitively intact resident with a history of behavioral issues, including physical aggression and noncompliance with care and medications, was located. The resident had been tapping or knocking on the window/door of the secured unit, drawing the attention of the dietary aide. Multiple staff, including a CNA and an RN, told the dietary aide not to go onto the secured unit, noting that the resident’s assigned aide could assist and that the resident had been agitated the previous day. Despite these instructions, the dietary aide went onto the secured unit. Witness statements and interviews indicate that upon entering the unit, the aide interacted with the resident, including offering to buy the resident a soda after seeing the resident holding money. According to staff statements and the aide’s own account, the resident then struck the aide in the face. The aide responded by punching the resident in the face. A CNA on the unit reported stepping between the two to attempt to deescalate the situation and then calling for the nurse due to the resident’s aggression. The CNA also reported hearing the aide tell the resident, “I will hit you again,” and then observed that the resident was bleeding. Following the punch, the resident was noted by staff to be bleeding from the nose and mouth. The resident was assessed by nursing and subsequently transported to the hospital. Hospital records documented that the resident sustained an open fracture of the right jaw, with a loose right lateral mandibular incisor and bleeding from the socket at the fracture site. The resident’s remaining 11 teeth were extracted because they could not be restored. A police report documented that staff reported the incident as an assault in which a staff member punched a resident after the resident had punched the staff member. The facility’s policy defined abuse as the willful infliction of injury resulting in physical harm, including physical abuse such as hitting and punching, and the facility substantiated that the dietary aide had physically abused the resident.
Failure to Ensure Safe Mechanical Lift Transfer, Timely Assessment, and Pain Management After Traumatic Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe mechanical lift transfers, adequate assessment, timely physician and representative notification, and appropriate pain management for a severely cognitively impaired, non‑ambulatory resident who required a mechanical lift with two‑person assistance for all transfers. The resident had multiple relevant diagnoses, including vascular dementia, osteoarthritis, a right hip prosthesis, chronic kidney disease, and a history of fractures and osteoporosis/osteopenia. On the morning of 04/22/26, during a mechanical lift transfer from bed to wheelchair, multiple CNAs reported that the sling appeared too small, the lift was pulled forcefully from under the bed, and the resident fell feet‑first out of the sling, with staff catching her upper body while both legs hit the floor and one leg bent behind her. A loud popping sound was heard, the resident screamed and cried out in pain, and witnesses observed immediate bruising, swelling, and apparent misalignment of the left knee/leg. Despite this, the nurse who responded did not perform a complete head‑to‑toe or range‑of‑motion assessment focused on the leg, and the incident was not documented as a fall from the lift. Following the incident, nursing staff actions and documentation were incomplete and inconsistent with the resident’s presentation. Progress notes on 04/22/26 documented only a skin tear to the left forearm and a head‑to‑toe assessment with no new areas, and there were no notes describing a fall, leg injury, or significant pain. Multiple CNAs and the resident’s roommate reported that the resident cried out in pain throughout the night and that her left leg appeared swollen, bruised, and deformed, yet nursing notes from the night shift only recorded administrations of acetaminophen without documenting the reason for administration, pain assessment findings, or any musculoskeletal concerns. One RN reported being asked to look at the resident on 04/22/26, noting swelling of the left leg but performing no further assessment. The physician was not notified within one hour of a suspected musculoskeletal injury as required by facility policy, and the resident’s representative was not informed that the resident had fallen from the mechanical lift. On 04/23/26, staff continued to report the resident’s ongoing pain and abnormal leg appearance, but the physician was contacted only about increased yelling and behavior, with a focus on agitation and prior hip/groin pain history rather than a new traumatic event. The DON later documented that a loud popping noise occurred during a Hoyer lift transfer with three staff present and that no abnormalities or signs of pain were noted, and the physician was asked to order bilateral hip and knee X‑rays as a precaution, without documenting a fall. Mobile X‑rays were obtained on 04/23/26, but the results, which showed a displaced distal femur fracture on a limited lateral view, were not reviewed until 04/24/26. Only then was the fracture acknowledged and discussed with the physician and resident representative. Subsequent hospital evaluation identified a closed displaced comminuted supracondylar fracture of the left femur and a distal fifth metacarpal fracture of the left hand. The facility’s internal investigation was incomplete and inaccurate: the DON denied a fall on 04/22/26, prepared a single typed statement describing only a popping sound while the resident was suspended over the bed, and had multiple staff sign it, even though at least two CNAs and an agency DON later reported that the statement was false and that staff felt intimidated and were told not to talk about the incident. The facility also failed to adequately manage the resident’s pain following the injury. Although the MAR shows acetaminophen administrations on 04/22/26 and early 04/23/26, there was no associated documentation of pain scores or clinical rationale in the progress notes for some doses, and staff interviews and the roommate’s account described the resident crying out in pain whenever touched and throughout the night. The physician later stated he was under the impression the fracture was non‑displaced and that, because the resident was bedbound, he did not feel she needed pain medication, and he was unaware of the severity of the femur fracture or the additional hand fracture. Overall, the facility did not follow its own physician communication policy for falls with musculoskeletal deformity or leg pain, did not perform and document thorough assessments at the time of the incident and during the subsequent night, did not promptly review diagnostic imaging, and did not conduct a complete, accurate investigation into the circumstances of the mechanical lift transfer and resulting injuries.
Improper Food Storage and Labeling in Facility and Resident Refrigerators
Penalty
Summary
Surveyors identified a failure to store food in accordance with professional standards and facility policy, creating the potential for foodborne illness for nearly all residents who received food from the kitchen. In the walk-in cooler, they observed multiple items that were opened and partially used without any open dates, including two cartons of heavy whipping cream, bins of individually poured and covered beverages, and a tray of covered fruit cocktail bowls. A large pan of pasta with ground meat was stored with the serving scoop resting directly on the food, covered with plastic wrap and not dated. A cart in the cooler held a 22-quart container of dark liquid with no label or date, and a pink plastic pitcher resting directly on the cart surface, which was coated with a dark unidentified material. A box of bacon was stored directly on the floor. The Director of Dietary Services confirmed the presence of undated, unlabeled, and improperly stored food items in the walk-in cooler. In the walk-in freezer, surveyors found an unsealed and undated bag of frozen chicken breasts and an unsealed and undated bag of pork pizza topping, which the Director of Dietary Services also confirmed. The reach-in cooler used for tray line contained a variety of pre-poured juices, milk, thickened beverages, and tea that were covered but not dated. At a nurses' station refrigerator, surveyors observed a plastic bag of food labeled with a resident’s name and dated more than a week earlier, along with three half-sandwiches wrapped in plastic without dates; the LPN present verified these findings. In a resident’s personal refrigerator, three undated bags of grapes with visible mold were found, and a CNA confirmed the grapes were moldy and undated. Facility policies required cold foods to be stored at least six inches above the floor, wrapped or in covered containers, labeled, and dated, and required resident refrigerators to be monitored daily, with food appropriately labeled and unsafe or moldy food discarded. These practices were not followed, resulting in the cited deficiency under the complaint investigation.
Unsanitary Kitchen Practices and Improper Dishwashing Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to unsanitary kitchen conditions, improper food labeling and dating, and failure to operate the dishwasher according to manufacturer and policy requirements. During an initial kitchen tour, they observed a plastic tray holding clean pitchers with a brown-like substance on it, and three open, three-shelf carts with crumbs and debris on the shelves where clean insulated plate lids and sleeves of disposable bowls, cups, and lids were stored. Multiple trays of juice in a reach-in refrigerator were open, unlabeled, and undated. In the walk-in refrigerator, surveyors found a plastic bag of bologna with only a freeze date and no thaw or use-by date; the bologna appeared slimy and lighter in color. The facility census was 67, with one resident identified as not receiving meals from the kitchen, and the deficiency was noted as having the potential to affect all residents receiving food from the kitchen. Surveyors also observed the high-temperature dishwasher in use and recorded a wash temperature of 168°F and rinse temperatures of 160°F, 176°F, 178°F, 178°F, and 178°F over five cycles, despite the machine label and facility policy requiring a minimum wash temperature of 150°F and a minimum rinse temperature of 180°F for hot water sanitizing. A staff member confirmed the dishwasher had not been running earlier that morning, verified it was a high-temperature machine that should rinse at a minimum of 180°F, and acknowledged the observations regarding the dirty tray, soiled carts, unlabeled juice, and improperly dated bologna. The staff member stated that items in the reach-in refrigerator were normally prepped the night before and asserted that the bologna always had that color before discarding it. Review of the dishwasher temperature logs for January through April 2026 showed repeated failures to meet required wash and rinse temperatures and numerous instances of missing documentation. In January, multiple wash temperatures were below the 150°F minimum, and several meals lacked recorded wash and rinse temperatures. February logs showed at least one sub-minimum wash temperature and many missing wash and rinse entries for various meals. March logs included at least one meal with no documented wash or rinse temperatures. April logs documented several wash temperatures below 150°F and rinse temperatures below 180°F, along with multiple days and meals where wash and/or rinse temperatures were not recorded at all. Facility policies on sanitation, kitchen infection control, and food receiving and storage required dishwashing to meet temperature and sanitation standards and refrigerated foods to be covered, labeled, dated, and used, frozen, or discarded by their use-by date, which was not consistently followed according to the survey findings.
Environmental Maintenance and Cleanliness Deficiencies in Resident Room and Common Restroom
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, clean, comfortable, and homelike environment as required by its “Homelike Environment” policy. Observation of a shared bedroom for Residents #46 and #56 showed wallpaper peeling from the wall in multiple locations, including behind each resident’s headboard, below the window, and near the baseboards. In the same room’s bathroom, a black substance was observed around the base of the toilet. During an interview conducted concurrently with these observations, CNA #175 confirmed the presence of the peeling wallpaper and the black substance around the toilet base. Further observation with CNA #175 in the C hall restroom revealed that three light covers in that restroom were cracked or broken. The facility’s written policy, revised in February 2021, states that residents are to be provided with a safe, clean, comfortable, and homelike environment. The conditions observed in the residents’ bedroom, bathroom, and the C hall restroom were inconsistent with this policy and affected two identified residents, with the potential to affect all residents in the facility.
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